whole systems integrated care whole systems integrated … · 2018. 1. 12. · dashboards and align...

WHOLE SYSTEMS INTEGRATED CARE

(WSIC) DASHBOARDS

COLLABORATION OF NWL CCGS

North West London Collaboration of Clinical

Commissioning Groups

Amanda Lucas, Programme Director. On behalf of the Collaboration of North West London Clinical Commissioning Groups

August 2017

Whole Systems Integrated Care

North West London Collaboration of CCG’s

2 | S l i d eSeptember 2017

Objectives of today’s session

1. Introduce the WSIC Dashboards and how we share

data across NWL

2. Explain how the dashboards are being used and

show you some of the visualisations being developed

on the personal health records

3. Explain how we are developing the product and

supporting adoption across the system

3 | S l i d e

Who is developing the WSIC Dashboards?Key enabler to North West London’s Sustainability and Transformation Plans (STPs)

11 August 2017

4 | S l i d e

NWL ISA Heat MapDigital Information Sharing Agreements (ISA) in place with 346 health and social care providers across the NWL system – covering over 1.5 million people to date

September 2017


WSIC Data Warehouse population

6 | S l i d e

Whole Systems Integrated Care (WSIC) solution

Clinical teams in secondary care

Care Coordinators

WSIC Data Warehouse

Researchers

Local Authorities Community

GPs

GP Practice

Long Term Condition Management Tools

Integrated Patient Summary

Case Finding Tools

Derived MeasuresLong Term Conditions

electronic Frailty Index (eFI)Spend

Reference DataOrganisation

BNFPostcode ‘out codes’

DE-

IDEN

TIFI

ED

ACPs

Population Health

Core DataActivity

PrescriptionsDemographics

Benchmarking De-identified dataset

District Nurses

Hospitals

September 2017


Analytics for Direct Care


How the WSIC Dashboards are being used to coordinate care for NWL patients

Using Betty’s story…..

Meet Sam and Betty• Betty 87, suffers from COPD, Type 2 diabetes and arthritis.• Coping well until Sam passed away, but now lonely and

increasingly depressed.• Frequently visits her GP and if she can't get hold of her GP

in a crisis calls for an ambulance.Using the WSIC Dashboards

• Care coordinator identifies Betty as a frequent A&E user and regular inpatient user on the patient radar

• Her activity timeline shows the care coordinator: A sudden increase in her activity across the system,

including a number of inpatient stays and A&E visits over the weekends;

She has not been treated for anything major in hospital;

She had a referral to social care but did not attend her appointment; and

She is attending at the practice weekly.


Use of the WSIC Dashboards

Case Managers use the WSIC Dashboards to create the following

reports…Timeframe

Where information will be found in the WSIC Dashboards

Care Plan tracking - List of patients with out of date care plans Monthly Using the ‘Care Plan out of date’ Watch List

Review of most expensive patients - Case find expensive patients that

have not been referred into My Care My Way (WL WSIC Hub) FortnightlyUse the ‘High Cost’ filter in the Patient radar

Produce list of patients with recent LTC diagnosis - use list a case finding

pointer or prompt for care plan review

MonthlyUsing the ‘Recently Diagnosed with a LTC’ Watch List

Produce list of regular In patient users - use list as case finding pointer

or prompt for care plan review

Monthly

Using the ‘Regular Inpatient attender’ filter in patient radar

Produce list of most frequent A&E attenders - Review as a prompt for

Care plan review and case finding

Monthly

Using the ‘Frequent A&E attendee’ Watch List

Produce LTC care plan out of date lists for follow up Monthly Using the ‘Care Plan out of date’ Watch List

The WSIC Dashboards are used by My Care My Way staff regularly to check patients that they are due to see to understand patterns of system activity and to case find using the reports detailed below

GP Referrals: Review patterns of activity

St Charles and Violet Melchett Hubs

Case Managers / HSCA Review

WSIC Dashboard reports:

Case finding

Shared patient view in MDT

meetings

All WLCCG practices incentivised to use the WSIC Dashboards in CLS Plan for 2017/18 to identify top 25 high cost patients for review


Analytics for Population Health Management


Plans for product development

1. Working with providers to develop use cases for both direct care and population health data.

2. Prioritising the most useful LTC patient radars to add to the WSIC Dashboards and align to the delivery areas in the NWL STP

3. Developing predictive analytics

4. Setting up direct provider data feeds to provide more frequent data flows for the purpose of direct care

5. Applying advanced analytics to inform understanding the population health to support accountable care development across NWL.

18 | S l i d e

Embedding and supporting adoption across the NWL health and social care system

• Focus to date has been on embedding the dashboards as the primary patient selection tool in the care coordination teams established across NWL

• Moreover in recognition of the potential benefits in the WSIC Dashboards, NWL CCGs are implementing incentives for GP practices as part of the Local Schemes

• Targeting clinical teams across primary, community, acute and social care who work as part of the Diabetes pathways in NWL for adoption of the Diabetes dashboards (and then other LTC pathways as new dashboards are developed).

September 2017

19 | S l i d e

Thank you for your time today

For more information on the WSIC Dashboards contact

[email protected]

September 2017

whole systems integrated care whole systems integrated … · 2018. 1. 12. · dashboards and align...

Documents